Tag Archives: Substance Abuse & Addictions

Substance Abuse & Addictions

Grief, loss and substance use

By Susan Furr and Derrick Johnson December 5, 2017

Andrew’s mother was so happy that he had finally agreed to enter treatment for his drinking problem. He had been an excellent college student until his hard partying began to take over his nights, leading to missed classes and incomplete assignments. He still managed to get a decent job that involved a lot of travel and client dinners. Andrew’s mom thought these responsibilities would help him settle down. What she didn’t realize was that he would begin using stimulants to keep up the hectic pace. When combined with his socially sanctioned business drinking, Andrew’s performance soon suffered.

Andrew managed to cover up the cracks in his professional veneer for several years before finally passing out one evening from a combination of exhaustion and alcohol. Thankfully, his company supported his entry into treatment, a move that encouraged his mother.

During one of the family visiting days, Andrew’s mother was thoroughly confused by his anger over giving up his substance. He had believed that treatment would help him “dry out” and then return to his previous life. “I don’t know why they expect me to give up people, places and things associated with my drinking,” Andrew lamented.

Andrew’s mother wanted to scream that this was such a small price to pay for Andrew to regain his life before it was too late. What she didn’t realize was that she had just encountered the first glimpse of Andrew’s grief related to recovery. Many other layers of grief would need to be uncovered and processed in the weeks and months ahead.

Confronting losses

You do not have to be an addictions counselor to encounter the grief related to substance use. I (Susan) worked for many years in a college counseling center and encountered students struggling with losses related to family members who were addicted. Substance use had taken away the parent they longed for.

For other students, siblings who were addicted created a range of issues, from trying to engage the student in substance use to wanting the student to “cover” for them. In the extreme, counselors may connect with students whose sibling overdosed while they were away at college, adding to their guilt because of a false belief that they could have prevented the act.

Given that college students are engaging in their own developmental issues around identity, they may be in a place to face these issues for the first time. Many college students begin to recognize some of the harmful effects created by the environments in which they lived.

Perhaps the most difficult case I encountered was a young woman who was beginning to address childhood sexual abuse perpetrated by her father. During our work together, her father contacted her to apologize for any harm he might have done, although he professed that his memories were cloudy because of his substance use. He was now in recovery and trying to make amends. Although his confession reaffirmed my client’s own memories, she was left grieving for the father she never had.

Groups such as Adult Children of Alcoholics evolved to support those whose lives have been upended by the addiction of someone else. In examining your client’s history, gathering information on any substance use issues in the family may go a long way toward helping the client understand the evolution of his or her current emotional challenges.

The loss of identity

Grief is often a forgotten aspect of recovery. Out of necessity, the need exists to focus on the physical aspects of addiction to alcohol and other drugs (AOD). These physical aspects of addiction are much more challenging than acknowledged by a “just say no” culture. Think about giving up that first cup of coffee each morning — for the rest of your life. And then multiply that impact manyfold.

Treatment programs have developed protocols to help clients navigate this process on a physical level, and support groups such as Alcoholics Anonymous (AA), Narcotics Anonymous and SMART Recovery help deal with the abstinence aspect of recovery. However, the idea of grieving the loss of one’s substance may seem contradictory to treatment. After all, giving up a destructive substance is a good thing — right? Regardless, any change, no matter how positive, often creates a sense of loss.

One way to think about this issue is to focus on the identity the client forms with the addictive substance rather than just thinking about giving up the substance. Clients often develop a positive view of self in terms of their substance, such as being able to “hold one’s liquor” or a female being able to “drink like a guy.” They gain a positive status for their drinking or drugging prowess; in other words, the user gains a sense of belonging and significance.

As substance use becomes a core value, social networks form around the experience of “using.” For example, one’s knowledge base and interest revolve around being aware of the best microbreweries or having a refined wine palette or even knowing the best place to buy meth. Identity begins to form around using and being with other users. The use of mobile apps that help “connoisseurs” identify and cross off “must-have” finds further increases the social lure of drinking and using substances. These items combine to develop an identity for the user and the onset of a relationship between the substance and the user.

More profound is the discovery of the purpose of substance use. Does it relieve anxiety in social situations or loosen inhibitions with potential relationship partners? How does the substance help the client cope with painful emotions caused by other losses? It is not uncommon for people to cope with a painful situation by going out for a drink, but for some, the substance becomes the go-to solution for any life stressor. I recall a bar that gave out a free drink for every job rejection letter that one of its patrons received. On the surface, this was a way to lighten the mood, but on a deeper level, it was just another way of teaching poor coping strategies — in this instance, managing loss through the use of substances.

Social networks can revolve around a culture of using. Stopping by the neighborhood bar after work may evolve into hanging out with the guys until closing time — dinner missed and a partner outraged. After awhile, users seem to prefer the company of fellow users over that of the distraught family. These gathering places often become part of a ritual, providing a structure that may normalize the damaging behavior. Recall the old TV show Cheers, “where everybody knows your name.” The act of walking in, seeing familiar faces and sharing a favorite drink creates a comforting routine that overshadows the underlying harm caused by abusing substances.

The grief aspects of recovery

To be successful in recovery, the client has to let go of all of the comforting aspects of using. These things must be grieved in order for the client to move forward.

Entering treatment means leaving behind the familiar and facing the unknown. On a cognitive level, giving up immediate gratification for future gains may make sense, but the actual experience of change also results in losses that need to be acknowledged.

Clinicians who understand the role that loss plays in recovery have devised activities, such as writing a goodbye letter to one’s substance, which recognize that even the loss of something that is ultimately negative needs to be grieved. It was through my work in grief and loss counseling that I first became aware of the loss associated with giving up one’s substance. Kathryn Hunsucker, a graduate student at the time, began applying the concept of loss to recovery and found that this concept resonated with her clients. We began working together to use some of the existing grief theories to conceptualize recovery in a way that made sense to clients. Derrick Johnson, an addictions counselor in Charlotte, North Carolina, has teamed with us to extend this approach to families. The theories of both J. William Worden and Therese Rando have been instrumental in helping us conceptualize the grief aspects of recovery.

Grief and loss show up in other phases of recovery too. Clients not only grieve giving up their substance and fellow users, but they also begin to examine losses throughout their lives. Once clients are engaged in ways of maintaining their abstinence and perhaps working through the steps of AA, they begin facing the choices that they made while using. In this phase of recovery, clients may begin to recognize that the consequences of their choices often involved a loss.

The underlying loss may be about the loss of the person the client once was or aspired to be. Some clients lament the loss of meaning in their life and their disconnection from spiritual or existential values. Often, however, there are more concrete losses that may include jobs, family, freedom and home. It is common to see the recognition of these losses emerge as clients address steps No. 8 and No. 9 of the Twelve Steps. Acknowledging those who have been harmed and making amends forces clients to see how they might have created their own losses.

The realization that this time can never be recaptured may trigger new waves of grief that can dampen the sense of hope that treatment initially fosters. Creating space for grieving is necessary to help cushion against relapse. This space is created by the counselor’s willingness to address the issue of loss directly. Clients often are surprised when the counselor asks them about the grief they experience in giving up their substance, but they are typically quite open to sharing what they will miss about using. If we pretend that no sense of loss exists, our clients will continue to avoid facing the losses that they will encounter in recovery.

Throughout the recovery process, clients often fight against memories of painful and traumatic experiences that may initially have contributed to their substance use. Counselors may be drawn to pursuing issues such as childhood sexual abuse early in treatment because the core nature of these events is linked to their clients’ emotional pain. However, until skills to maintain abstinence are developed and more recent losses have been grieved, it may be more productive to focus on the skills needed to contain these feelings. Kathryn Hunsucker, who is now an addictions specialist in Morehead City, North Carolina, suggests “bookmarking” these issues and returning to them at a later date — ideally when clients have formed the strength to encounter the pain associated with these losses.

Metaphors and other creative approaches

Derrick Johnson saw his practice change after adding grief counseling as part of his approach in treating addiction. Of specific interest is his use of “love” as a metaphor.

Derrick has clients think of a romantic love or someone very special to them whom they lost due to the person’s death. Derrick then asks his clients to list both the positive and negative aspects of their relationship with this person. After examining these relational attributes, Derrick next asks, “Did you stop loving that person the moment you said goodbye?” Of course, the reply is “no.” The use of this metaphor creates understanding and generates recognizable feelings and thus becomes a cognitive tool for clients to make the connection to their experience of giving up a substance.

Another example could be the termination of an intimate relationship. Again, although saying goodbye leads to a newly defined relationship status, it does not mean that love immediately stops. Through group discussion, members are able to understand that just because they love someone does not automatically qualify it as a healthy relationship. Similarly, love of or use of a substance does not equal compatibility. This parallels AOD abuse/dependence, which is not compatible with successful life engagements and life fulfillment. Through this metaphor, clients are able to draw parallels between giving up a substance and the loss of a relationship.

Acknowledging that it is OK to grieve the loss of the substance is essential to helping clients move through that initial fear of giving up or losing something. It is no different than acknowledging the passing of a loved one or the end of a relationship. Would counselors take that away from a client who is mourning? Of course not.

Engaging in creative approaches to help clients visualize their losses can also be valuable. Kathryn often uses an activity that starts with a handout, “What Baggage Do You Carry,” illustrated with different types of suitcases. She asks clients to fill the bags with the losses they carry around with them because of their addictions. Clients then explore what it would mean to take items out of their bags to lessen their loads. Emotions related to giving up the items are then examined. This is one concrete way for clients to increase awareness of the losses they may need to grieve.

Another awareness activity Kathryn uses is “Life Event Bingo.” In this activity, group members are given bingo cards featuring different life events in each square. Group members are instructed to mingle to try to find someone who has experienced a particular life event in the past year and to learn what coping techniques worked best for the person in that situation. Group members then record the person’s name and coping strategy in the appropriate box. The goal is to find a different person for each box so that group members make connections with others and explore different ways to deal with life challenges.

It is important to allow clients to discuss and make a list of those things that they miss about using. Though contrary to intuitive treatment protocol, it is important to remember that people use substances to alter their feelings, which means that the complete spectrum of feelings must be explored. This process involves careful one-on-one work between the client and therapist that can uncover a multitude of clues about why a client uses substances.

For example, when Derrick worked at a 90-day intensive outpatient facility, the identification of engagement and belonging was a key factor in uncovering the etiology of one client’s substance dependence. Specifically, this binge drinker identified fall and winter as “just my perfect time.” Upon closer examination, Derrick discovered that attending NFL football games and tailgating prior to the games provided this client with a keen sense of belonging. Thus, giving up drinking also meant saying goodbye to his ritual and way of belonging. This client had to grieve the loss of his ritual and what the loss represented as it related to his identity.

Closing thoughts

Grief and loss issues are essential to explore when working with people living with addictions but, frequently, this focus is left out because of the many competing issues that arise. Although those who are in treatment gain a new understanding of what it means to grieve the loss of their substance of choice, this process may be confusing to those in their support networks. The family just wants the person back whom they lost to addiction. We need to be sensitive to the losses faced by families who have their own grief to explore. They, too, have lost hopes and dreams that were shattered by addiction. Even with effective treatment, the person who returns to them has been changed by the addiction experience and will need to continue to work on personal abstinence.

Families may need additional support as they work to reintegrate their family member returning from treatment. Groups such as Al-Anon can provide needed encouragement and understanding. But as is the case with all losses, grief must be faced and experienced as part of the healing process. Often, the lessons learned from the loss can lead to an enriched way of living, both for the family and the person in recovery.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Susan Furr is a professor in the Department of Counseling at the University of North Carolina at Charlotte (UNC Charlotte). She had 16 years’ experience working at the university’s counseling center before moving to teaching. Her interests include grief and loss counseling, crisis intervention and counselor development. She is an active member of the International Association of Addictions and Offender Counselors (a division of the American Counseling Association), where she is the editor of IAAOC News. Contact her at SusanFurr@uncc.edu.

Derrick Johnson is a doctoral student at UNC Charlotte with research interest in the association of grief, loss and addiction. He is senior clinical addiction therapist at Legacy Freedom Treatment Center and also has a private practice in Charlotte.

 

 

 

 

 

Letters to the editor: ct@counseling.org

 

 

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Giving children a voice in addiction recovery

By Bethany Bray December 4, 2017

When treating clients struggling with substance abuse, Lindsey Chadwick would like her fellow counselors to keep in mind the toll that addiction takes on children. Addiction affects the whole household. Children feel the effects differently — but as acutely — as adults, says Chadwick, a licensed professional counselor and manager of the children’s program at the Betty Ford Center, part of the Hazelden Betty Ford Foundation, just outside of Denver, Colorado.

“Simply being aware [of the fact] that kids are affected by addiction is a huge piece of the advocacy work that we do,” says Chadwick, a member of the American Counseling Association. “Even if a counselor is working [in addictions] with adults, be thinking of the kids. They are a big part of their grown-ups’ recovery. They matter. Take into account what the kids have to say.”

Chadwick and her colleagues run a program for children, ages 7 to 12, who come from addicted homes. The child’s “grown-up,” a parent, relative or caregiver, receives treatment simultaneously through the Betty Ford Center’s programming for adults. The children come for an intensive, four-day workshop that focuses on coping skills and education on what addiction is, and – most importantly – that it’s not their fault, says Chadwick.

“Most of all, we try and help them have fun and be a kid. They are often caught up in very grown-up situations at home,” says Chadwick.

Children from homes where  addiction is present often  take on roles they’re too young to play, such as caring for younger siblings or being a peacemaker or mediator in the home, she

Lindsey Chadwick at work in the children’s program at the Betty Ford Center just outside of Denver, Colorado.

explains. At Betty Ford, Chadwick and her colleagues do a lot of role-play, sharing activities and psychoeducational games with the children, as well as non-therapeutic games, snacks and swimming at a nearby pool.

“For the most part, on the surface, our kids look like any other kids,” says Chadwick. “But we see a lot who are struggling with anger toward their grown-up or family members. We see a lot of very anxious and nervous kids who have taken on a lot of adult roles because they needed to.  Some of our kids have also experienced abuse and neglect. Addiction is an equal-opportunity disease, so we see it in all kinds of families.”

Children who come through the program often struggle with perfectionism, an extreme focus on maintaining control and “not making waves,” says Chadwick. Also, children who come from addicted homes often experience loneliness and guilt or feel like their family is not as good as others.

Many children feel like the addiction is somehow their fault – a message they focus on reversing, says Chadwick.

“We teach them that many people go through what they’re going through,” she says. “We want them to really learn their strengths. Despite the addiction, it doesn’t mean that they can’t love their family, or that other things [in their life] aren’t going well.”

In households with addiction, feelings and problems are not usually talked about or addressed. This unwritten “rule” of not talking about struggles or emotions is passed from older to younger generations, Chadwick says. At Betty Ford, they work to undo those patterns, teaching children to express what they’re feeling – with an aim to keep them from falling into addiction when older.

“A lot of our kids don’t have the language [to express the struggles of addiction]. We try to give them the language to talk about what’s going on, to identify what’s wrong and tell someone,” says Chadwick. “… We give them the space to know that they matter, and it’s OK to let things out.”

In addition to talking to express themselves, they teach the youngsters nonverbal ways to let out their emotions, such as drawing, physical activity and other self-care activities. They also identify who is safe to talk to (i.e., a counselor, trusted adult or peer) and when. “Addiction sometimes confuses that for them,” explains Chadwick.

“We have kids who come in, and they’re angry, sad or mad, and they don’t want to be here,” she says. “On the last day [of the program], they’re happy and smiling – they’re a kid again. It’s such a wonderful transformation to be a part of.”

Psychoeducation activities at the Betty Ford children’s program also involve a cartoon character named Beamer. He stars in a series of books that the Betty Ford Center uses in their children’s program.

Both of Beamer’s parents struggle with addiction, and one is in recovery, and the other is not, explains Chadwick. Beamer navigates the ups and downs of living in a household coping with addiction in each of the books.

“Kids really love Beamer because they’ve never really seen a character that’s going through the same things as they are,” Chadwick says. “It’s very validating to learn that they’re not alone. They relate to him. A lot of the situations he’s been in, they’ve been in – his struggles at school and interactions with family. It gives them a vehicle to talk about it as well, and helps them feel more comfortable.”

Betty Ford counselors sometimes encourage the children to write Beamer letters as a therapeutic tool, adds Chadwick.

All families who go through recovery programs at the Betty Ford Center are referred for therapy in their local area. They are also invited back for weekly follow-up programming and support groups.

Chadwick has worked for nine years at the children’s program at the Betty Ford Center. In addition to Chadwick’s program in Colorado, Betty Ford also offers children’s programming at centers in Dallas and Rancho Mirage, California.

“I grew up in a family where addiction was a problem for multiple generations. I saw things that I shouldn’t have as a kid. I’m happy to give back to these families,” says Chadwick. “It’s so amazing, as a therapist, you get to work with the kids on their level and have so much fun throughout the day, but also help focus on recovery … It’s really amazing to watch these families heal. The adults in the [Betty Ford Center] program really want what’s best for their families, and it’s wonderful to be part of that process.”

 

 

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Find out more about the Hazelden Betty Ford Foundation’s children’s program at hazeldenbettyford.org/treatment/family-children/childrens-program

More information on the “Beamer” character and materials can be found at mybeamersworld.com

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and Facebook at facebook.com/CounselingToday.

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

 

FASD: A guide for mental health professionals

By Jerrod Brown July 10, 2017

Fetal alcohol spectrum disorders (FASD), which researchers have estimated affect 2 to 5 percent of the U.S. population, are lifelong conditions that result from exposure to alcohol in utero. Kenneth L. Jones, David W. Smith and colleagues are credited with discovering the birth defects and long-term impacts on cognitive and social functioning caused by fetal alcohol syndrome in 1973.

Prenatal alcohol exposure can result in a host of issues related to:

  • Cognitive functioning (e.g., impulse control, attention, executive functioning)
  • Social functioning (e.g., communication skills, recognition of social cues)
  • Adaptive functioning (e.g., problem-solving, ability to adapt to new situations)

Furthermore, several neurological issues characterize FASD, including stunted cell and nerve growth, elevated rates of cell mortality, neurotransmitter interruptions and migration issues in organic brain growth. Complicating matters, the overwhelming majority of individuals with FASD experience an array of psychiatric disorders, increasing the likelihood that these individuals will need specialized services from mental health care providers.

Unfortunately, many of these providers and professionals lack the necessary training and expertise to accurately identify and effectively treat the unique and complex symptomatology of this population. The goal of this article is to provide a basic introduction of FASD to mental health professionals in six key areas: FASD symptoms, diagnostic comorbidity, memory impairments, tips for interacting with individuals who may have FASD, screening and assessment, and treatment.

FASD symptoms

A diverse range of symptoms characterizes FASD.

Executive functioning deficits: Impairments associated with executive functioning are a hallmark deficit of FASD, impacting the majority of individuals affected by these disorders. Executive functioning deficits are often associated with impulsivity, diminished ability to learn from consequences and impairments in planning, verbal reasoning, emotional regulation, memory and learning.

Social skills deficits: Individuals with FASD often have pervasive impairments in the domain of social functioning. Misinterpretation of social cues is not uncommon. This can lead to boundary violation concerns (e.g., inappropriately touching another person), which can in turn result in involvement in the criminal justice system. Such social skill deficits can also increase the individual’s level of vulnerability to manipulation by others and an inability to detect unsafe situations and people.

Attachment problems: Consistent with these deficits in social skills, poor attachment with the primary caregiver is relatively common in children with FASD. Poor attachment with the primary caregiver can increase the likelihood of misdiagnosis in a child. Common misdiagnoses may include attention-based (e.g., attention-deficit/hyperactivity disorder [ADHD]) or behavior-based disorders (e.g., conduct and oppositional defiant disorders). In fact, it is not uncommon for these disorders to co-occur with a diagnosis of FASD. Given that reality, mental health professionals who work with individuals impacted by FASD should familiarize themselves with commonly co-occurring disorders such as those just mentioned.

Adaptive functioning: Adaptive functioning involves an individual’s practical, social and mental capacities to deal with everyday challenges and problems (e.g., personal hygiene, personal finances, navigating social interactions). In light of the executive functioning problems outlined earlier, as well as struggles with processing abstract information and solving problems, individuals with FASD have difficulty in the realm of adaptive functioning. The consequences can range from difficulty maintaining employment to struggles with caring for one’s self. Because of these deficits in adaptive functioning, a high percentage of individuals with FASD are dependent on the support of family and social services.

Learning problems: One of the key issues related to adaptive functioning among individuals with FASD is difficulty learning from past experiences. Furthermore, individuals with FASD often struggle to use past experience to prospectively avoid dangerous people and situations. These deficits are exacerbated by impulsivity and an inability to think strategically about decisions. Hence, FASD affects an individual’s ability to understand society’s norms and to behave within those norms.

Diagnostic comorbidity

Increasing the likelihood of negative short- and long-term outcomes, individuals with FASD often have co-occurring disorders and other issues.

Diagnostic comorbidity: It has been estimated that the overwhelming majority of individuals with FASD experience comorbid psychiatric conditions. ADHD is the most prevalent comorbid disorder observed among those affected by FASD. Other disorders frequently observed among adolescents with FASD include conduct disorder and oppositional defiant disorder. Finally, individuals with FASD are also at an elevated risk to abuse substances later in life.

Physical complications: A number of physiological symptoms can suggest the possibility of FASD. For example, prenatal alcohol exposure can result in cardiovascular (e.g., septal defects, hypoplastic pulmonary arteries) and kidney (e.g., pyelonephritis, hydronephrosis, hypoplasia) irregularities. Prenatal alcohol exposure has also been linked to orthopedic irregularities in the structure of bones in the upper body (e.g., radioulnar synostosis), fingers and toes (e.g., camptodactyly, brachydactyly, clinodactyly).

Other brain-based injuries: Individuals with FASD may be more prone to traumatic brain injuries throughout the life span. This could contribute to the underdiagnosis and misdiagnosis of FASD. Furthermore, these traumatic brain injuries may exacerbate other secondary conditions, including ADHD, executive functioning impairments, mental health and substance use disorders, and so on.

Other life adversities: As a function of FASD and these other co-occurring disorders and impairments, individuals with FASD are disproportionately likely to be afflicted with problematic life experiences. For example, individuals with FASD often come from unstable homes, experience neglect and abuse (verbal, physical or sexual), and are exposed to substance use, mental illness and criminal justice involvement by their families and household members. As such, mental health professionals should view these co-occurring disorders and other negative life experiences as potential indicators of FASD, necessitating a need for further assessment and evaluation.

Memory

One of the most devastating cognitive deficits of FASD is short- and long-term memory impairment.

Poor memory: Individuals with FASD typically have problems associated with memory. In some instances, these issues can lead to over- and underendorsement of symptoms, contributing to missed and misdiagnosis. In other instances, these individuals can struggle with retrieving and communicating their memories, contributing to issues such as suggestibility, confabulation, fabricating stories and incorrect storytelling.

Suggestibility: The suggestibility of individuals with FASD can be detrimental in at least two ways. First, these individuals may be manipulated into participating in criminal activity by peers. Second, these individuals may be prone to falsely confessing to criminal activities that they did not commit. As such, mental health professionals must take care to verify the accuracy of statements made by individuals with FASD. Mental health professionals should also take the topic of suggestibility into account when phrasing and asking questions during the initial intake and diagnostic assessment process.

Confabulation: FASD and other disorders characterized by memory deficits often co-occur with confabulation issues. Confabulation occurs when new memories are created by filling gaps in recall with one’s real memories, imagination or environmental cues. Incidents of confabulation may occur spontaneously or be prompted. For example, confabulation is particularly likely in situations in which professionals ask leading questions or pressure the interviewee. As such, confabulation can contribute to inaccurate self-reports by the client, resulting in possible misdiagnosis and the development of an ineffective treatment plan.

Interacting with clients

The pervasive symptoms of FASD have important implications for how mental health professionals should interact with clients who may have these disorders.

Importance of simplicity: Individuals with FASD tend to perform better when tackling one task at a time. This is especially true of tasks that do not involve reliance on previous experience to complete. Multistep and complex questioning can result in individuals with FASD shutting down emotionally or responding with factually incorrect or incomplete responses. Mental health professionals should take this into account when screening, assessing and developing treatment plans for this population.

Superficial talkativeness: The propensity for individuals diagnosed with FASD to be charming and talkative may lead mental health professionals to overestimate their level of competence and comprehension of treatment goals. It is important for clinicians to have these individuals demonstrate understanding and knowledge of the question being asked by explaining it back to the professional in their own words. Overuse of yes-or-no questioning can also mask the individual’s true level of impairment.

Misinterpretation of callousness: In some cases, behaviors resulting from FASD symptoms might be mistaken as a choice rather than as a result of the disorders. The social and cognitive deficits of individuals with FASD can contribute to problematic behaviors being misinterpreted as premeditated or manipulative. In fact, many of the behaviors exhibited by individuals with FASD are the direct result of deficits caused by prenatal alcohol exposure.

Screening and assessment

The combination of nuanced symptomatology and diagnostic comorbidity makes the screening and diagnosis process for FASD difficult.

Diagnostic terminology: FASD is an all-encompassing term that includes fetal alcohol syndrome, partial fetal alcohol syndrome, alcohol-related neurodevelopmental disorder and alcohol-related birth defects. In the fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), neurodevelopmental disorder-associated with prenatal alcohol exposure has been added as a condition for further study. This is the first appearance of FASD-related symptoms in the DSM, which means mental health professionals can now diagnose prenatal alcohol exposure.

Missed and misdiagnosis: Missed and misdiagnoses of FASD may explain, at least in part, the limited awareness of the disorders among medical and mental health professionals. A lack of systematic education and training on FASD contributes to this situation. As a result, many children, youth and adults go unidentified and are subsequently unable to take advantage of advanced medical and psychological treatment and services that could render a better quality of life.

Detection difficulties: Another factor that likely contributes to the missed and misdiagnoses of FASD is the fact that these disorders are difficult to identify. Why is that? Visible indicators such as morphological signs are not always present, whereas cognitive deficits are difficult to detect using standardized intelligence measures. This is problematic because individuals with FASD who present with no outward signs of facial feature abnormalities can still possess severe neurobehavioral deficits. In fact, diagnosis of prenatal alcohol exposure becomes increasingly difficult as children grow into adolescence and adulthood. Specifically, many of the physical features of prenatal alcohol exposure fade as children grow physically. Furthermore, the availability of birth mothers and records decrease with time. As a result, many professionals and researchers have called FASD a “hidden disability.”

Importance of identification: Assessment and identification of FASD are essential because the likelihood of impairment related to alcohol exposure increases significantly with each subsequent pregnancy. Identification of these disorders in a first pregnancy provides a viable point of intervention to help prevent alcohol use in future pregnancies.

Treatment

Even in cases in which the individual has been accurately diagnosed with FASD, treatment can be challenging.

Problems with cognitive-based treatments: Individuals with FASD have cognitive (e.g., memory, understanding cause-and-effect), social (e.g., comprehending social cues) and adaptive (e.g., problem-solving ability, generalizing skills) deficits that complicate their participation in cognitive-based treatment. Likewise, insight-based therapy approaches are not encouraged with this population. Therapeutic approaches that incorporate modeling, coaching, teaching and skill building may be most effective with these individuals.

Problems with treatment adherence: Individuals with FASD may benefit more from treatment in structured residential facilities than in outpatient facilities because of the cognitive deficits associated with FASD. Should an outpatient program be the only option, odds of treatment success may be improved by maximizing program structure and tailoring treatment plans to the individual.

Conclusion

The disorders under the FASD umbrella are complex and lifelong. They are characterized by an array of adaptive, behavioral, emotional, executive, physical and social impairments. Considering the prevalence rates of FASD in the United States, it is highly likely that mental health professionals will come into frequent contact with individuals impacted by these disorders. Unfortunately, these disorders often go unrecognized and undiagnosed by many mental health professionals.

Other than simply improving identification of individuals with FASD, another essential step for mental health professionals is to better understand the various challenges and deficits faced by this population on a daily basis. To combat the status quo, mental health professionals are encouraged to seek training on this complex topic and consult with FASD experts when necessary. Taking this path forward will minimize the likelihood of negative short- and long-term outcomes for this population.

 

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Jerrod Brown is the treatment director for Pathways Counseling Center Inc., which provides programs and services benefiting individuals affected by mental illness and addictions. He is also the founder and CEO of the American Institute for the Advancement of Forensic Studies and the editor-in-chief of Forensic Scholars Today. He holds graduate certificates in autism spectrum disorder, other health disabilities and traumatic brain injuries, and is certified as a fetal alcohol spectrum disorders trainer. Contact him at Jerrod01234Brown@live.com.

 

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having your article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Opioid SOS

By Laurie Meyers May 31, 2017

During a single afternoon this past August, 26 people overdosed on opioids in Huntington, a small city in West Virginia with a population of approximately 50,000. Bolstered by naloxone — an opioid antidote that often can revive overdose victims who have stopped breathing — and too much practice in overdose scenarios, police and paramedics were able to save all 26 people. However, the danger of overdosing is so great — and so common — that many of those 26 individuals are likely to overdose again, some fatally.

Scenes of opioid overdoses are playing out again and again in cities, towns and rural areas across the United States. So many Americans are in thrall to opioids — which encompass both prescription pain relievers and the illegal drug heroin — that the Centers for Disease Control and Prevention (CDC) has declared opioid abuse an epidemic. According to the CDC, in 2015 (the latest year data were collected) more than 33,000 Americans died from opioid overdoses, a number that is quadruple the rate of deaths in 1999. In fact, from 2000 to 2015, more than half a million deaths were attributed to opioid overdose. West Virginia, New Hampshire, Kentucky, Ohio and Rhode Island are the states with the highest rates of opioid deaths, but no state, no socioeconomic status and no racial or ethnic group can claim to remain untouched by the opioid epidemic.

“We’re in danger of losing a generation,” asserted Carol Smith at an April congressional briefing on Capitol Hill sponsored by the American Counseling Association to raise awareness about the opioid epidemic and the role professional counselors can play in stemming the tide. Smith, a member of ACA and a past president of the West Virginia Counseling Association, is a counseling professor and the coordinator of the violence, loss and trauma certificate of studies at Marshall University — which happens to be located in Huntington.

Birth of an epidemic

The CDC numbers show that the opioid epidemic has been gathering steam for a long time. Public awareness of the epidemic has grown gradually with media reports of more fatal overdoses, including the startling 2016 death of music legend Prince by overdose from nonprescribed fentanyl. More than a year later, the full story is not yet known, but the singer and musician had reportedly been taking prescription opioids for chronic pain for many years, which put him at risk for developing an addiction.

In fact, for many of the people who become addicted to opioids, this is how it begins — with a prescription for painkillers. According to the CDC, prescriptions for opioids in the U.S. have quadrupled since the year 2000, despite there being no corresponding overall increase in the amount of pain that Americans report. Experts say a combination of factors has driven the sharp rise in opioid prescriptions. In the late 1990s, in a push to improve pain management, the medical community began considering pain a fifth vital sign, along with body temperature, pulse rate, respiration rate and blood pressure. The prescription drug OxyContin debuted in 1996 and was marketed as less addictive than other opioids. Research that has since been discredited asserted that patients in severe pain had a low tendency to become addicted to opioids.

“That was simply not true,” says Kirk Bowden, a licensed professional counselor (LPC) and ACA fellow in Phoenix who has specialized in addictions for almost 30 years. “They found that [severe pain] patients did start to become addicted — very early on. You can become addicted even if you follow the physician’s directions.”

Experts say that certain populations are particularly at risk for becoming addicted to opioids, including individuals who have a history of trauma, mental illness or other substance abuse. Medical professionals such as doctors, nurses, dentists and veterinarians are at increased risk because they have easy access to opioids through their work. Those in the military are also at greater risk because they are so often treated for pain.

As Smith points out, opioids are particularly addictive because of the effect they have on a person’s mind and body. “We are all biologically vulnerable,” she says.

Opioids attach to opioid receptors in the body to reduce the sensation to pain. As they do this, they cause physical changes in the body’s own opioid system. Over time, the body may become physically dependent on opioids. Even a weeklong prescription for opioids can cause withdrawal at cessation. In addition, opioids affect the brain’s reward system and can cause a feeling of euphoria. This combination of effects means that long-term use is itself a risk factor for physical dependence and addiction. A study reported in the March 17 issue of the CDC’s Morbidity and Mortality Weekly Report found that in patients prescribed opioids for the first time, the likelihood of them still being on the opioid within a year’s time increased after just six days of use and then again at 31 days.

Unfortunately, Smith Says, doctors and dentists commonly prescribe 30-, 60- or 90-day supplies of opioids to help patients alleviate instances of even short-term pain, such as the removal of wisdom teeth.

Some people who become addicted while on painkillers turn to heroin once their prescription runs out or when other opioids become too expensive, says ACA member Kevin Doyle, an LPC who has a private practice that specializes in group work for clients who have substance use disorders. It is becoming more common for heroin to be mixed with fentanyl, which is a much stronger opioid. Frequently, he notes, users either don’t know about the fentanyl or misjudge the dose and end up overdosing.

Addiction as a lifelong illness

There is a common misconception, not just on the part of the average person but also by many health professionals, that “getting sober” (clearing the body of the addictive substance) and recovery are the same thing. Nothing could be further from the truth, say substance abuse experts.

All of the counseling professionals interviewed for this article say that the standard for addiction treatment for both inpatient and outpatient programs is typically 30 days to get biologically clean. Clients are then sent back into their home environments, where they can easily become addicted again in the absence of follow-up support.

“You hear numbers about treatment programs that have outrageous treatment success rates, like 98 percent, but they don’t say where people are five years later,” Bowden notes. “People new to [addiction and recovery] don’t realize how addiction encompasses your whole life. … Long-term support is critical.”

ACA member Larry Ashley, an LPC with more than 40 years in the field of addictions, agrees. He says that as hard as getting “sober” or physically clean may be, it is actually the easiest part of recovery. “Recovery is a lifestyle change,” he says. “It’s important that people understand the difference between sobriety and recovery.”

Smith adds that addiction is most often treated like an acute disease when it is actually a chronic one, and the challenges don’t just stem from staying off the substance.

Doyle agrees. “There is a tendency to think of this [addiction treatment] as a single episode — that once you take care of that, we are done,” he says. “But, unfortunately, it’s a lifelong disease, and like any other disease, there may be episodes when a person doesn’t take as good of care of themselves as [other times]. I tell the client upfront, ‘We don’t see a cure, but this is something that can be managed.’”

The cost of not seeking help for addiction is high, and the opioid epidemic has been particularly devastating. ACA member Rick Carroll, a counselor who helped develop the substance abuse certification program at Lindsey Wilson College, has seen many people lose everything to opioids. And like a bomb blast, the destruction from addiction is not limited to the person hooked on opioids — it spreads outward.

In fact, the fallout from opioid abuse is what spurred the state of Kentucky, where the main campus of Lindsey Wilson College is located, to fund Carroll’s certification program. Currently, 1 in 4 babies born in Kentucky is diagnosed with neonatal abstinence syndrome — a range of physical problems that result from being exposed to opioids in the womb. The babies and mothers receive any needed addiction treatment and health care at the hospital, but there is also a need for clinicians who can help mothers cope with bonding and other family issues while undergoing detox.

Carroll also does parental assessments in Virginia for social services and the local court system. He sees many parents who have lost their children to foster care because of opioid abuse and estimates that a third of these clients will never regain custody of their children.

Many problems associated with addiction cannot be addressed with a 30-day program because recovery involves rebuilding a life, say the counselors interviewed for this article. In many instances, these clients have a lot to “relearn,” Carroll says.

“In our program, we talk about meeting people where they are at,” he says. “Which stage of change are they in? Do they say that they have a [substance abuse] problem? Where are they in recognizing the problem?”

People often take substances such as opioids as a way to cope, so counselors can help these clients by teaching them healthy coping skills, Carroll says. This starts by teaching them to be mindful and pay attention to their emotions, particularly becoming aware of when they are experiencing negative emotions such as anxiety and depression. Journaling can be helpful as a kind of daily log of thoughts and feelings, says Carroll, adding that some clients feel more connected to their emotions when they write them down.

As clients learn to be mindful of their emotions, they also need to be presented with new ways to cope, Carroll says. Among the tools he shares with clients are relaxation techniques and systematic desensitization. Carroll says that counselors should talk to clients about the events and everyday situations that are most stressful for them and have them practice breathing and other relaxation techniques that they can continue to use on their own. Counselors can also teach clients how to better deal with conflict through role-play and empty chair exercises, he says.

People who struggle with addiction are also often dealing with significant cognitive distortions, such as thinking that they are damaged goods, Carroll explains. Counselors can help clients examine these beliefs to see either that the beliefs aren’t valid or to clearly identify problems that clients can work on.

It is also important for counselors to understand the dynamics of these clients’ family systems, Carroll says. In some cases, family relationships have been broken or the client’s family members are struggling with addiction themselves. In either case, the client is faced with a lack of support and a potentially triggering environment, he says.

Carroll advises the use of genograms to explore family dynamics, looking in particular for toxic relationships or indications of a multigenerational history of substance abuse or mental illness. Through the use of genograms, “clients can see the roots [of their difficulties] and ask, ‘What can I create in my life right now to break the cycle?’” Carroll says.

Ashley, who also specializes in combat trauma, says that clients struggling against addiction also need to learn different ways to alter their consciousness and feel good. “People who have been addicted for a long time don’t know how to have fun,” he says. Ashley advises asking these clients about the activities that they used to enjoy and encouraging them to find or rediscover hobbies because they need alternatives to getting high.

“Exercise is good as long as they don’t overdo it,” he says. “Reading, bowling, going for a walk, art — it just depends. If you never had any experience [with hobbies], you have to try. If it doesn’t work, keep on trying.”

Ashley says clients also need to develop a plan to stay sober. These plans address elements such as how to stay away from situations or people that trigger or encourage substance use and abuse, how to handle stress and other emotions without opioids or other drugs, what to do when the urge to use strikes and how to occupy the time that previously went to scoring and taking drugs. Although counselors can assist clients with these plans, Ashley says it is equally important that they help clients find additional support through avenues such as group therapy, 12-step support meetings and other treatment programs if necessary.

Carroll agrees. “Counselors need to work closely with other health providers, medical professionals, social workers and school personnel,” he says. “It’s very imperative that you don’t work within a bubble. Get the individual the best help that you can.”

Necessary knowledge

Counselors can serve as a vital source of support for clients in recovery, but many practitioners have little or no training in addictions work. Bowden firmly believes that counselors need intensive training to work with those struggling with addictions.

Smith asserts that the grip of the opioid epidemic is so strong that all counselors must learn how to work with these clients. Likewise, counselors who specialize in substance abuse issues note that all practitioners will encounter clients who are struggling with addiction, even if addiction isn’t the presenting issue. Smith adds that clients may not reveal substance abuse problems right away, meaning that by the time the subject of addiction comes up, a therapeutic bond likely will have been established already with the counselor.

That is not to suggest, however, that the proper training isn’t important. Counselors should seek out additional courses on addictions work, either locally or online. Bowden and Ashley urge counselors to undergo supervision and to find a specialist with whom they can work. Counselors can also get involved with professional organizations such as the International Association of Addictions & Offender Counselors, a division of ACA.

“No matter what your practice is based on, most of your people are going to have addiction issues, whether obvious or not,” Ashley says. “So get to know people in the 12-step community. Look in the Yellow Pages or go online and Google ‘support groups,’ including options that aren’t [connected to] AA [Alcoholics Anonymous].”

When working with individuals who are battling addiction, Smith says, counselors also shouldn’t forget to simply call on the fundamentals of counseling. “A person needs to know that they are in safe company, with someone who is empathetic and who understands at least a little bit what they are going through and is willing to act as a guide.”

 

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Larry Ashley, Kirk Bowden, Kevin Doyle and Carol Smith each served as panelists (along with Dr. Melinda Campopiano of the federal Substance Abuse and Mental Health Services Administration) at the congressional briefing on opioid abuse in April that was sponsored by ACA. For a report on that briefing, read the online exclusive, “‘We’re in danger of losing a generation,’” by Bethany Bray at CT Online (ct.counseling.org).

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association.

Counseling Today (ct.counseling.org)

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Opioid Use Disorder” by Rachel M. O’Neill
  • “Substance Abuse and Addictive Disorders” by Gerald A. Juhnke & Kathryn L. Henderson
  • “Chronic Pain Counseling” by Stephanie T. Burns

Books (counseling.org/publications/bookstore)

Podcasts (counseling.org/knowledge-center/podcasts)

  • “The Latest on Addiction Counseling, Co-Occurring has Replaced Dual-Diagnosis and Why is Crack so Addictive Anyway?” with Ford Brooks and Bill McHenry

ACA divisions

  • International Association of Addictions & Offender Counselors (iaaoc.org)

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editorct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

‘We’re in danger of losing a generation’

By Bethany Bray April 5, 2017

When a person is prescribed medicine by a doctor, the common assumption is that it’s best to take the dosage until it’s gone.

In most cases, that’s true. But with opioids, a class of powerful, addictive and frequently prescribed pain relievers, dependence on the drug can begin within five days. Yet doctors often prescribe a 30-day supply, said Carol Smith, a licensed professional counselor (LPC) who spoke at an April 4 congressional briefing on Capitol Hill that was sponsored by the American Counseling Association.

“By the end of the 30 days, [the opioid] is not addressing their pain anymore. It’s a vicious, vicious cycle,” said Smith, a professor of counseling at Marshall University in West Virginia and past president of the West Virginia Counseling Association.

Carol Smith, LPC and professor of counseling at Marshall University, speaks at ACA’s congressional briefing on opioids on April 4. At left is panelist Larry Ashley, LPC, LMSW and professor emeritus of counseling at the University of Nevada, Las Vegas. Photos by Bethany Bray/Counseling Today

Smith, a member of ACA, was speaking as part of a panel that focused on the realities of America’s opioid epidemic and how professional counselors are well-suited to help change that trajectory.

“What counselors bring to the table is essential to any response to this crisis,” said panelist and ACA member Kevin Doyle, a professor of counselor education at Longwood University who also has a private counseling practice in Charlottesville, Virginia. “This touches everyone. … Virtually no element of society is immune to this.”

The opioid class includes heroin as well as prescription pain relievers such as oxycodone, Vicodin and morphine. On average, 91 people across the U.S. die every day from opioid overdoses, according the U.S. Centers for Disease Control and Prevention. The amount of prescription opioids sold in the U.S. has nearly quadrupled since 1999; deaths from prescription opioids have more than quadrupled since 1999.

In the U.S., more than 650,000 opioid prescriptions are dispensed every day, said panelist and ACA member Kirk Bowden, an LPC who chairs the addiction and substance use disorder program at Rio Salado College in Arizona.

Opioids should be for acute, not chronic, pain, Bowden said. He also stressed the need for more training for medical professionals on the dangers of dispensing opioids.

For example, patients who have had oral surgery to remove their wisdom teeth are commonly prescribed a 30-day supply of opioids, when in most cases the drugs are only needed for a few days of pain relief, Bowden said. Patients then leave the remaining pills in their medicine cabinets, easily accessible to anyone in the household.

“[With opioids] if individuals use it, even as prescribed, over time the individual will become addicted,” said Bowden. “Something drastic needs to happen. … Over half a million people died between 2000 and 2015 from opioids. That’s like the city [the size] of Atlanta.”

“We’re in danger of losing a generation,” said Smith, who lives in West Virginia, a state with one of the highest opioid overdose rates in the U.S.

“As [Bowden] succinctly put it, we need to remember that this issue is not a singular crisis but a chronic problem that demands that we marshal all available resources to combat,” said Art Terrazas, ACA’s director of government affairs.

Panelists told congressional staff members attending the ACA-sponsored briefing that solutions need to include more addictions training for medical professionals, better access to care and support programs for people struggling with opioid addiction, and the inclusion of professional counselors in response efforts to the opioid crisis.

Kevin Doyle, LPC and professor of counselor education at Longwood University in Virginia speaks as Dr. Melinda Campopiano of the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) looks on.

Counselors use a strengths-based approach and work to address the underlying reasons, such as past trauma, that individuals may turn to opioids to self-medicate, Smith explained.

“What counselors can bring to all of this is an attention to the whole person,” she said. “We come at it from a wellness perspective, and build on [a client’s] strengths. … We teach self-regulation and how to stay grounded in the here and now. We help people to know how to be sad in a healthy way, how to be angry in a healthy way and what to do with those emotions. Many people come to counseling and they can’t even identify that they’re angry. It’s been trained out of them by life experience.”

Counselors are uniquely skilled to support clients in their recovery goals – and in their possible relapses, Doyle added.

“We stick with them through the ups and downs,” he said. “We know that with treatment, recovery is possible.”

 

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Watch a video of ACA’s Congressional briefing on opioids here: youtu.be/tqcEKMTqsaE

 

Download ACA’s infographic on opioids here: bit.ly/2p0ZJ0N

 

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Dillon Harp of ACA’s Government Affairs team (far right) moderates the panel, from left to right Dr. Melinda Campopiano, Kevin Doyle, Kirk Bowden, Larry Ashley and Carol Smith.

About the panelists

Larry Ashley is a licensed professional counselor (LPC), licensed master social worker (LMSW) and professor emeritus of counseling at the University of Nevada, Las Vegas and addiction specialist at the University of Nevada, Reno School of Medicine. A U.S. Army veteran, he specializes in the treatment of military clients and issues related to combat trauma.

Kirk Bowden, an LPC and ACA fellow, is past president of NAADAC, the Association for Addiction Professionals, chair of the addiction and substance use disorder program at Rio Salado College, and consultant and subject matter expert for Ottawa University.

Dr. Melinda Campopiano is a physician and the chief medical officer of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration. She is board-certified in family medicine and addiction medicine.

Kevin Doyle, LPC, is a professor in the counselor education program at Longwood University and chair of the department of education and special education. He has served three terms on the Virginia Board of Counseling and runs a private practice in Charlottesville, Virginia.

Carol Smith, LPC, is a professor of counseling at Marshall University and coordinates Marshall’s Violence, Loss and Trauma Certificate of Advanced Studies program. She is past president of the West Virginia Counseling Association, a branch of ACA.

 

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

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